Case 5: Neovascular Glaucoma
A 66-year-old man presented with loss of vision in his right eye. He also complained of severe achy pain in and around the eye. The pain “felt like a toothache” and had developed gradually over several days.
One year earlier the patient had sustained a central retinal vein occlusion (CRVO) in his right eye. Because the CRVO was ischemic, he had undergone several sessions of panretinal laser photocoagulation. His vision remained impaired after the CRVO episode.
The patient had type 2 diabetes mellitus, hypertension, and hypercholesterolemia. He had been a smoker for more than 40 years but quit smoking 3 years earlier. His medical history included a myocardial infarction and cardiac bypass surgery.
The patient had no light perception in the right eye. Visual acuity was 20/30 in the left eye.
The episcleral vessels were dilated in the right eye. On slit lamp examination the iris showed florid neovascularization (rubeosis). This was confirmed with gonioscopy, which is used to evaluate the anterior chamber angle. The patient had a mature white cataract in his right eye and had some early nuclear sclerosis in his left eye. He also had an afferent pupillary defect in the right eye. His intraocular pressure was 58 mm Hg in the right eye and 23 mm Hg in the left eye. The back of the right eye was not visible because of the dense cataract. The left fundus appeared normal except for narrowing of the retinal arteries and arteriovenous nicking.
Neovascular glaucoma attributable to the ischemic CRVO was diagnosed. Even with laser treatment, ischemic CRVO may progress in some patients to neovascularization of the retina and rubeosis. Additional laser treatment is not practical in this case because of the patient’s dense cataract, which makes visualization of the fundus impossible.
This patient was treated with medical therapy; topical corticosteroids and atropine(Drug information on atropine) sulfate 1% were prescribed to decrease pain and inflammation. A topical β-blocker (timolol 0.5%), a topical α-agonist (brimonidine tartrate 0.2%), and a topical carbonic anhydrase inhibitor (dorzolamide 2%) were also prescribed. He was told to use all these eye drops in his right eye only.
Medical therapy is usually short-term. More permanent treatment options include retinal cryotherapy, to reduce the stimulus for further neovascular formation; retrobulbar alcohol(Drug information on alcohol) injection; and enucleation.
The patient’s general medical status was stable because he had seen his cardiologist 2 days before his ophthalmological visit.